GALEN COLLEGE OF NURSING
Course Code: NSG 3250
Instructor:
Date: 2026
FINAL EXAM – NURSING PRACTICE ADULT HEALTH I
1. A 68-year-old patient with chronic atrial fibrillation presents to the emergency department with
sudden onset of severe left leg pain, pallor, and absent pedal pulses. The leg is cold to touch. What
is the priority nursing action?
A) Elevate the leg above heart level B) Apply warm compresses to improve circulation C) Keep
the leg in a dependent position and notify the physician immediately D) Massage the leg to restore
circulation
Answer: C Rationale: These symptoms indicate acute arterial occlusion, likely from an embolus
originating in the fibrillating atria. The leg should remain dependent (below heart level) to
maximize whatever blood flow exists via gravity. Elevation decreases arterial flow. This is a
surgical emergency requiring immediate intervention (embolectomy or thrombolysis). Never
massage - this could dislodge the clot. The "6 Ps" are: Pain, Pallor, Pulselessness, Paresthesia,
Paralysis, Poikilothermia (coldness).
2. A patient with chronic kidney disease has the following laboratory values: potassium 6.8 mEq/L,
calcium 7.2 mg/dL, phosphorus 6.5 mg/dL. Which ECG change is most concerning and requires
immediate intervention?
A) Prolonged QT interval B) Peaked T waves C) Shortened QT interval D) Flattened T waves
Answer: B Rationale: Hyperkalemia (>5.5 mEq/L) causes peaked T waves initially, progressing
to widened QRS, prolonged PR interval, and eventually ventricular fibrillation or asystole. Peaked
T waves indicate dangerously high potassium requiring immediate treatment with calcium
gluconate (membrane stabilization), insulin/glucose, sodium bicarbonate, or dialysis. Prolonged QT
occurs with hypocalcemia (which this patient also has) but hyperkalemia is immediately life-
threatening.
3. A post-operative patient develops sudden dyspnea, chest pain, and hemoptysis three days after
total hip replacement. Oxygen saturation is 88% on room air. What is the most likely complication?
1
,A) Myocardial infarction B) Pneumonia C) Pulmonary embolism D) Atelectasis
Answer: C Rationale: The classic triad of dyspnea, chest pain, and hemoptysis suggests
pulmonary embolism (PE), though all three symptoms are present in only 20% of cases.
Orthopedic surgery, particularly hip/knee replacement, significantly increases DVT/PE risk due to
immobility, vessel trauma, and hypercoagulability. Three days post-op is a common timeframe.
Immediate interventions include oxygen, elevation of head of bed, IV access, and preparation for
anticoagulation after diagnostic confirmation (CT pulmonary angiography or V/Q scan).
4. A patient with type 1 diabetes presents with blood glucose 650 mg/dL, pH 7.15, positive serum
ketones, and fruity breath odor. Which intervention is the priority after establishing IV access?
A) Administer regular insulin IV bolus followed by continuous infusion B) Administer sodium
bicarbonate to correct acidosis C) Administer 0.9% normal saline rapidly D) Administer potassium
chloride immediately
Answer: C Rationale: This patient has diabetic ketoacidosis (DKA). While all interventions may
eventually be needed, initial treatment prioritizes fluid resuscitation with 0.9% normal saline (1-2
liters in first hour) to correct severe dehydration and improve perfusion. After fluid resuscitation
begins, regular insulin continuous infusion starts (0.1 units/kg/hr). Potassium is added to IV fluids
when levels are <5.3 mEq/L and urine output is adequate. Bicarbonate is rarely used (only if pH
<6.9) as insulin therapy corrects acidosis by stopping ketone production.
5. A patient receiving chemotherapy for lung cancer develops neutropenia (ANC 450 cells/mm³).
Which instruction is most important?
A) Avoid fresh fruits and vegetables B) Report temperature of 100.4°F (38°C) or higher
immediately C) Limit fluid intake to prevent bladder irritation D) Take temperature rectally for
accuracy
Answer: B Rationale: Neutropenic patients (ANC <500) are severely immunocompromised.
Fever ≥100.4°F (38°C) indicates neutropenic sepsis requiring immediate broad-spectrum
antibiotics - mortality can reach 50% without prompt treatment. The patient should avoid
raw/unwashed produce (neutropenic diet). Rectal temperatures are contraindicated (risk of mucosal
trauma and bacteremia). Adequate hydration is essential, especially with chemotherapy.
6. A patient admitted with acute pancreatitis has severe epigastric pain radiating to the back. Which
position provides the most pain relief?
A) Supine with legs extended B) Right lateral side-lying position C) Sitting up and leaning forward
D) Prone position
Answer: C Rationale: The inflamed pancreas causes severe pain when pressed against the
posterior abdominal wall. Sitting up and leaning forward or a side-lying position with knees drawn
to chest moves the pancreas away from the posterior wall, reducing pressure and pain. The fetal
position also helps. Supine positioning worsens pain. Additional interventions include NPO status,
NG tube if vomiting/ileus, IV fluids, and pain management (avoid morphine - may cause sphincter
of Oddi spasm).
2
, 7. A patient recovering from anterior wall MI develops jugular venous distention, hypotension,
muffled heart sounds, and narrowed pulse pressure. What complication has most likely occurred?
A) Cardiogenic shock B) Cardiac tamponade C) Right ventricular infarction D) Acute mitral
regurgitation
Answer: B Rationale: Beck's triad (hypotension, JVD, muffled heart sounds) indicates cardiac
tamponade from pericardial effusion compressing the heart. Anterior wall MI can cause pericarditis
and subsequent effusion. Narrowed pulse pressure occurs as diastolic pressure rises while systolic
drops. This is a medical emergency requiring pericardiocentesis. Pulsus paradoxus (>10 mmHg
drop in systolic BP with inspiration) may also be present. Immediate preparation for emergency
pericardiocentesis is essential.
8. A patient with cirrhosis develops confusion, asterixis (flapping tremor), and elevated ammonia
levels. Which medication is most appropriate?
A) Neomycin B) Lactulose C) Furosemide D) Spironolactone
Answer: B Rationale: These symptoms indicate hepatic encephalopathy from elevated ammonia
levels. Lactulose is first-line treatment - it acidifies the colon, trapping ammonia as ammonium ion
and promoting its excretion through catharsis. Goal is 2-3 soft stools daily. Rifaximin (antibiotic) is
also used to reduce ammonia-producing gut bacteria. Neomycin is an older option with more
toxicity. Protein restriction is no longer recommended. Diuretics treat ascites but don't address
encephalopathy.
9. A patient with COPD has ABG results: pH 7.32, PaCO₂ 58 mmHg, HCO₃⁻ 30 mEq/L, PaO₂ 58
mmHg. What is the correct interpretation?
A) Uncompensated respiratory acidosis B) Partially compensated respiratory acidosis C)
Compensated respiratory acidosis D) Metabolic acidosis with respiratory compensation
Answer: C Rationale: The pH is slightly acidic (7.32, normal 7.35-7.45), indicating acidosis.
PaCO₂ is elevated (respiratory acidosis), and HCO₃⁻ is also elevated (metabolic compensation).
Since pH is nearly normal, this represents compensated respiratory acidosis, typical in chronic
COPD. The kidneys have retained bicarbonate to buffer chronic CO₂ retention. Partial
compensation means pH remains abnormal; full compensation means pH returns to normal range.
10. A patient with suspected stroke arrives within the thrombolytic window. Which finding is an
absolute contraindication to tPA administration?
A) Blood pressure 185/105 mmHg B) Current use of aspirin 81 mg daily C) Ischemic stroke 2
months ago D) Blood glucose 250 mg/dL
Answer: C Rationale: Previous stroke within 3 months is an absolute contraindication to tPA due
to hemorrhagic transformation risk. Blood pressure >185/110 mmHg is a relative contraindication
requiring treatment to lower BP before tPA. Aspirin use is not a contraindication, though current
anticoagulation is. Hyperglycemia should be treated but isn't a contraindication. Other absolute
contraindications include active bleeding, intracranial hemorrhage history, recent major surgery,
and bleeding disorders.
3
Course Code: NSG 3250
Instructor:
Date: 2026
FINAL EXAM – NURSING PRACTICE ADULT HEALTH I
1. A 68-year-old patient with chronic atrial fibrillation presents to the emergency department with
sudden onset of severe left leg pain, pallor, and absent pedal pulses. The leg is cold to touch. What
is the priority nursing action?
A) Elevate the leg above heart level B) Apply warm compresses to improve circulation C) Keep
the leg in a dependent position and notify the physician immediately D) Massage the leg to restore
circulation
Answer: C Rationale: These symptoms indicate acute arterial occlusion, likely from an embolus
originating in the fibrillating atria. The leg should remain dependent (below heart level) to
maximize whatever blood flow exists via gravity. Elevation decreases arterial flow. This is a
surgical emergency requiring immediate intervention (embolectomy or thrombolysis). Never
massage - this could dislodge the clot. The "6 Ps" are: Pain, Pallor, Pulselessness, Paresthesia,
Paralysis, Poikilothermia (coldness).
2. A patient with chronic kidney disease has the following laboratory values: potassium 6.8 mEq/L,
calcium 7.2 mg/dL, phosphorus 6.5 mg/dL. Which ECG change is most concerning and requires
immediate intervention?
A) Prolonged QT interval B) Peaked T waves C) Shortened QT interval D) Flattened T waves
Answer: B Rationale: Hyperkalemia (>5.5 mEq/L) causes peaked T waves initially, progressing
to widened QRS, prolonged PR interval, and eventually ventricular fibrillation or asystole. Peaked
T waves indicate dangerously high potassium requiring immediate treatment with calcium
gluconate (membrane stabilization), insulin/glucose, sodium bicarbonate, or dialysis. Prolonged QT
occurs with hypocalcemia (which this patient also has) but hyperkalemia is immediately life-
threatening.
3. A post-operative patient develops sudden dyspnea, chest pain, and hemoptysis three days after
total hip replacement. Oxygen saturation is 88% on room air. What is the most likely complication?
1
,A) Myocardial infarction B) Pneumonia C) Pulmonary embolism D) Atelectasis
Answer: C Rationale: The classic triad of dyspnea, chest pain, and hemoptysis suggests
pulmonary embolism (PE), though all three symptoms are present in only 20% of cases.
Orthopedic surgery, particularly hip/knee replacement, significantly increases DVT/PE risk due to
immobility, vessel trauma, and hypercoagulability. Three days post-op is a common timeframe.
Immediate interventions include oxygen, elevation of head of bed, IV access, and preparation for
anticoagulation after diagnostic confirmation (CT pulmonary angiography or V/Q scan).
4. A patient with type 1 diabetes presents with blood glucose 650 mg/dL, pH 7.15, positive serum
ketones, and fruity breath odor. Which intervention is the priority after establishing IV access?
A) Administer regular insulin IV bolus followed by continuous infusion B) Administer sodium
bicarbonate to correct acidosis C) Administer 0.9% normal saline rapidly D) Administer potassium
chloride immediately
Answer: C Rationale: This patient has diabetic ketoacidosis (DKA). While all interventions may
eventually be needed, initial treatment prioritizes fluid resuscitation with 0.9% normal saline (1-2
liters in first hour) to correct severe dehydration and improve perfusion. After fluid resuscitation
begins, regular insulin continuous infusion starts (0.1 units/kg/hr). Potassium is added to IV fluids
when levels are <5.3 mEq/L and urine output is adequate. Bicarbonate is rarely used (only if pH
<6.9) as insulin therapy corrects acidosis by stopping ketone production.
5. A patient receiving chemotherapy for lung cancer develops neutropenia (ANC 450 cells/mm³).
Which instruction is most important?
A) Avoid fresh fruits and vegetables B) Report temperature of 100.4°F (38°C) or higher
immediately C) Limit fluid intake to prevent bladder irritation D) Take temperature rectally for
accuracy
Answer: B Rationale: Neutropenic patients (ANC <500) are severely immunocompromised.
Fever ≥100.4°F (38°C) indicates neutropenic sepsis requiring immediate broad-spectrum
antibiotics - mortality can reach 50% without prompt treatment. The patient should avoid
raw/unwashed produce (neutropenic diet). Rectal temperatures are contraindicated (risk of mucosal
trauma and bacteremia). Adequate hydration is essential, especially with chemotherapy.
6. A patient admitted with acute pancreatitis has severe epigastric pain radiating to the back. Which
position provides the most pain relief?
A) Supine with legs extended B) Right lateral side-lying position C) Sitting up and leaning forward
D) Prone position
Answer: C Rationale: The inflamed pancreas causes severe pain when pressed against the
posterior abdominal wall. Sitting up and leaning forward or a side-lying position with knees drawn
to chest moves the pancreas away from the posterior wall, reducing pressure and pain. The fetal
position also helps. Supine positioning worsens pain. Additional interventions include NPO status,
NG tube if vomiting/ileus, IV fluids, and pain management (avoid morphine - may cause sphincter
of Oddi spasm).
2
, 7. A patient recovering from anterior wall MI develops jugular venous distention, hypotension,
muffled heart sounds, and narrowed pulse pressure. What complication has most likely occurred?
A) Cardiogenic shock B) Cardiac tamponade C) Right ventricular infarction D) Acute mitral
regurgitation
Answer: B Rationale: Beck's triad (hypotension, JVD, muffled heart sounds) indicates cardiac
tamponade from pericardial effusion compressing the heart. Anterior wall MI can cause pericarditis
and subsequent effusion. Narrowed pulse pressure occurs as diastolic pressure rises while systolic
drops. This is a medical emergency requiring pericardiocentesis. Pulsus paradoxus (>10 mmHg
drop in systolic BP with inspiration) may also be present. Immediate preparation for emergency
pericardiocentesis is essential.
8. A patient with cirrhosis develops confusion, asterixis (flapping tremor), and elevated ammonia
levels. Which medication is most appropriate?
A) Neomycin B) Lactulose C) Furosemide D) Spironolactone
Answer: B Rationale: These symptoms indicate hepatic encephalopathy from elevated ammonia
levels. Lactulose is first-line treatment - it acidifies the colon, trapping ammonia as ammonium ion
and promoting its excretion through catharsis. Goal is 2-3 soft stools daily. Rifaximin (antibiotic) is
also used to reduce ammonia-producing gut bacteria. Neomycin is an older option with more
toxicity. Protein restriction is no longer recommended. Diuretics treat ascites but don't address
encephalopathy.
9. A patient with COPD has ABG results: pH 7.32, PaCO₂ 58 mmHg, HCO₃⁻ 30 mEq/L, PaO₂ 58
mmHg. What is the correct interpretation?
A) Uncompensated respiratory acidosis B) Partially compensated respiratory acidosis C)
Compensated respiratory acidosis D) Metabolic acidosis with respiratory compensation
Answer: C Rationale: The pH is slightly acidic (7.32, normal 7.35-7.45), indicating acidosis.
PaCO₂ is elevated (respiratory acidosis), and HCO₃⁻ is also elevated (metabolic compensation).
Since pH is nearly normal, this represents compensated respiratory acidosis, typical in chronic
COPD. The kidneys have retained bicarbonate to buffer chronic CO₂ retention. Partial
compensation means pH remains abnormal; full compensation means pH returns to normal range.
10. A patient with suspected stroke arrives within the thrombolytic window. Which finding is an
absolute contraindication to tPA administration?
A) Blood pressure 185/105 mmHg B) Current use of aspirin 81 mg daily C) Ischemic stroke 2
months ago D) Blood glucose 250 mg/dL
Answer: C Rationale: Previous stroke within 3 months is an absolute contraindication to tPA due
to hemorrhagic transformation risk. Blood pressure >185/110 mmHg is a relative contraindication
requiring treatment to lower BP before tPA. Aspirin use is not a contraindication, though current
anticoagulation is. Hyperglycemia should be treated but isn't a contraindication. Other absolute
contraindications include active bleeding, intracranial hemorrhage history, recent major surgery,
and bleeding disorders.
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